Permit CITY OF TIGARD ELECTRICAL PERMIT
s COMMUNITY DEVELOPMENT Permit#: ELC2022-00767
T I[;A j{t3 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 11/17/2022
Parcel: 2S103DA00700
Jurisdiction: Tigard
Site address: 13205 SW WATKINS AVE
Project: Anderson Subdivision: DERRY-DELL Lot: 7
Project Description: Converting oil furnace to gas.
Contractor: Owner: ANDERSON, DENNISE
10595 SW 71ST AVE
PORTLAND, OR 97223
PHONE:
PHONE:
FAX:
FEES
Quantity Description Date Amount
1 crt Branch Circuits wo/Purchase 11/17/2022 $56.18
Specifics: Service or Feeder
1 ea 12%State Surcharge- 11/17/2022 $6.74
Type of Use: SF Electrical
Class of Work: ALT
Type of Const:
Occupancy Grp:
Total $62.92
Required Items and Reports(Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, Slate of OR. Specialty Codes and all other applicable law. All work will
be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the
180 days. ATTENTION: Ore n law requires you to follow then rules adopted by the Oregon Utility Notification Center. f Those rules are set forth,-in OAR
952-001-0010 through OAR 9 -001-0090. You may oAain}a:coy f tpe rules or direct auestions to OUNC by calling 503.232.1987 or1y�.33 234.
Issued By: �)/^Il /v`l�u J /'l Permittee Signature:
OWNER INSTALLATION ONLY
The installation is being made on property I own which is not intended for sale,lease or rent.
OWNER'S SIGNATURE: Date:
CONTRACTOR INSTALLATION ONLY
SIGNATURE OF SUPR.ELEC'N Date:
LICENSE NO.
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the Job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
Electrical Permit Application FOR OFFICE USE ONLY'
CityofTigard Received
Date/B : IitIt 11111111111111
54 u 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
g Phone: 503.718.2439 Fax: 503.598.1960 Date/B : Related Permit#.
Inspection Line: 503.639.4175 Ready Date/By: tuns: 63 See Page 2 for
7I G A it.D Internet: www.tigard-or.gov Notified/Method: Supplemental Information
TYPE OF WORK PLAN REVIEW
❑New construction ,:0 Addition/alteration/replacement Please check all that apply(submit 2 sets of plans w/items checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
❑Demolition ❑Other: where the available fault current 0 Marinas and boatyards.
CATEGORY OF CONSTRUCTION exceeds 10,000 amps at 150 volts or 0 Floating buildings.
less to ground,or exceeds 14,000 0 Commercial-use agricultural
❑ 1-and 2-family dwelling ❑Commercial/industrial 0 Accessory building amps for all other installations. buildings.
❑Multi-family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or
JOB SITE INFORMATION ANHV/CATION 0 Emergency system larger separately derived
p _ ❑Addition of new motor load of system.
Job#: Job site address: /, ' C>,5 `1 (,L i 4-4--k i�S I00HP or more. ❑"A"•"E'•"1-2"•'I-3
0 Six or more residential units. occupancy.
City/State/ZIP: ���frt, I - g 7 22_5 0 Health-care facilities. 0 Recreational vehicle parks.
Hazardous locations. 0 Supply voltage for more than
Suite/bldg./apt.#: Project name: 0
❑Service or feeder 600 amps or more. 600 votes nominal.
Cross street/directions to job site: FEE SCHEDULE
Description I Qty. I Each I Total
New residential single-or multi-family dwelling unit.
Subdivision: Lot#: Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea add'l 500 sq.ft.or portion 33.92 1
DESCRIPTION OF WORK Limited energy,residential 75.00 2
(with above sq.ft.)
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
Renewable Energy 0 See Page 2
yz PROPERTY OWNER ❑ TENANT Services or feeders installation,alteration,and/or relocation
Name: jt/�(/CC .h .„.0 f 200 amps or less 100.70 2
� Q—rr// 201 amps to 400 amps 133.56 2
Address: f $>��(�.1 ni� 401 amps to 600 amps 200.34 2
City/State/ZIP: }- ,P_-- -Z 601 amps to 1,000 amps 301.04 2
Phone:(-T ) y y /1 Fax:( ) Over 1,000 amps or volts 552.26 2
/ / Temporary services or feeders installation,alteration,and/or
Email: !'C�f f 3/ �_ �\t�/L,� _ . ' A , relocation
Owner installation: is installation is be made on property that I own which is not 200 amps or less 59,36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signature: Date: 401 amps to 599 amps 168.54 2
El APPLICANT I ❑ CONTACT PERSON
Branch circuits—new,alteration,or extension,per panel
A.Fee for branch circuits with
r} above service or feeder fee,
Business name: d .(�y!(.� 7.42 2
`�I each branch or feeder
Contact name: B.Fee for branch circuits without
service or feeder fee,first 56.18 2
Address: branch circuit t
Each add'l branch circuit 7.42 2
City/State/ZIP: Miscellaneous(service or feeder not included)
Phone:( ) Fax: :( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: Reconnect only 67.84 2
CONTRACTOR Pump or irrigation circle 67.84 2
Business name: I ` �k j.,4 QC�
'/�� Sign or outline lighting 67.84 2
I —I Signal circuit(s)or limited-energy 0 See Page 2 2
Address: panel,alteration,or extension.
Each additional inspection over allowable in any of the above
City/State/ZIP: Additional inspection(1 hr min) 66.25/hr
Phone:( ) Fax:( ) Investigation(1 hr min) 90.00/hr
Industrial plant(1 hr min) 78.18/1u
Email: Inspections for which no fee is
specifically listed(V;hr min) 90.00/hr
CCB Lic.: Electrical Lic.: Suprv.Lic.: ELECTRICAL PERMIT FEES
Suprv.Electrician signature,required: Subtotal:
Print name: Date: 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
( TOTAL PERMIT FEE: ;69{ 9.'
Authorized signature: l v This permit application expires if a permit is not obtained within ISO
,, �/ /y h� // ' /l/)i days after it has been accepted as complete.
Print name: 1 :I l -011(10 lr l / Date: /1�1 �/'/ + Numberof inspections allowed per permit.
I:\Building\Permds\Ei9LC_PPer nitr App_ ERE..doc Rev 006//1177//2\015'"1'l/ 4404615/TO /Ol55//C—O6M/WEB
Electrical Permit Application—City of Tigard
Page 2—Supplemental Information
Limited Energy Permit Fees: Renewable Energy Permit Fees:
RESIDENTIAL WORK ONLY: FEE SCHEDULE
[laudation •
Fee for all residential systems combined: $75.00 Renewable
Qty. i Each I Total I electrical energy systems:
Check Type of Work Involved: 5 kva or less 100.70 2
5.01 to 15 kva 133.56 2
❑ Audio and Stereo Systems* 15.01 to 25 kva 200.34 2
Wind generation systems in excess of 25 kva:
❑ Burglar Alarm 25.01 to 50 kva 301.04 2
50.01 to 100 kva 552.26 2
❑ Garage Door Opener* >100 kva(fee in accordance 552.26 2
with OAR 918-309-0040)
❑ Heating, Ventilation and Air Conditioning Solar generation systems in excess of 25 kva:
System* Each additional kva over 25 7.42 3
[] Vacuum Systems* >100kva—no additional charge 0.0 3
Each additional inspection over allowable in any of the above:
❑ Other: Each additional inspection is 66.25/hr
charged at an hourly(1 hr min)
Inspections for which no fee is 90 00/hr
specifically listed('h hr min)
COMMERCIAL WORK ONLY: ELECTRICAL PERMIT FEES
Fee for each commercial system: $75.00 Subtotal(Enter on Page 1):
y ' Number of inspections allowed per permit.
(SEE OAR 918-309-0000)
Check Type of Work Involved:
❑ Audio and Stereo Systems
❑ Boiler Controls
❑ Clock Systems
❑ Data Telecommunication Installation
❑ Fire Alarm Installation
❑ HVAC
❑ Instrumentation
❑ Intercom and Paging Systems
❑ Landscape Irrigation Control*
❑ Medical
❑ Nurse Calls
❑ Outdoor Landscape Lighting*
❑ Protective Signaling
❑ Other:
Total number of commercial systems:
*No licenses are required. Licenses are required for all
other installations
I:1nuilding\Permds\ELC PvmrtApp_ELR_ERE.doc Rev 06/17/2015
Property Owner Statement
Regarding Construction Responsibilities
Oregon Law requires residential construction permit applicants who are not licensed with the
Construction Contractors Board to sign the following statement before a building permit can be
issued. (ORS 701.325 (2))
This statement is required for residential building, electrical, mechanical, and plumbing permits.
Licensed architect and engineer applicants, exempt from licensing under ORS 701.010(7),need not
submit this statement. This statement will be filed with the permit.
Please check the appropriate box:
own, reside in, or will reside in the completed structure and my general contractor is:
----...•� --
Name CCB# Expiration Date
I will inform my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
or
I will be performing work on property I own, a residence that I reside in, or a residence that I will
reside in. If I hire subcontractors, I will hire only subcontractors licensed with the Construction
Contractors Board. If I change my mind and hire a general contractor, I will select a contractor
who is licensed with the CCB and will immediately give the name of the contractor to the office
issuing this Building Permit.
I have read and understand the Information Notice to Homeowners About Construction Responsibilities,
and I hereby certify that the information on this homeowner statement is true and accurate.
AV i N' �y /Y"7C t ° "
Print Name of Permit Applicant /(
7
/ l /ZDZ
Signa e of Permit Applicant Date
Permit#:
`-4
Address: .�,7,1,*-
<J
Issued by: Date: FAA;
This Copy for Permit Offices
:�� '�. information Notice to Owners About
'' i.t,;,` Co s r c ron Responsibilities
`nri.v (ORS 701.325 (3))
Homeowners acting as their own general contractors to construct a new home
or make a substantial improvement to an existing structure, can prevent many problems
by being aware of the following responsibilities:
® Homeowners who use labor provided by workers not licensed by the Construction Contractors
Board, may be considered an employer, and the workers who provide the labor may be considered
employees. As an employer, you must comply with the following:
t, Oregon's Withholding Tax Law: Employers must withhold income taxes from employee wages
at the time employees are paid. You will be liable for the tax payments even if you don't actually
withhold the tax from your employees. For more information, call the Department of Revenue at
503-378-4988.
▪ Unemployment Insurance Tax: Employers are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more information, call the Oregon Employment
Department at 503-947-1488.
• Oregon's Business Identification Number (BIN): is a combined number for both Oregon
Withholding and Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or go to
htto:/lwww.oregon.4ov/DOR/BUS/dots/211-055.Ddf for the appropriate forms.
• Workers Compensation Insurance: Employers are subject to the Oregon Workers Compensation
Law, and must obtain Workers Compensation Insurance for their employees. If you fail to obtain
Workers Compensation Insurance, you could be subject to penalties and be liable for all claim costs
if one of your workers is injured on the job. For more information, call the Workers Compensation
Division at the Department of Consumer and Business Services at 503-947-7815.
O Tax Withholding: Employers must.withhold Social Security Tax and Federal Income Tax from
employee wages. You may be liable for the tax payment, even if you didn't actually withhold the tax.
For a Federal EIN number, call the IRS at 1-800-829-4933 or visit their website at www.irs.gov.
Other Responsibilities of Homeowners:
• Code Compliance:As the permit holder for a construction project, the homeowner is responsible
for notifying building officials at the appropriate times, so that the required inspections can be
performed. Homeowners are also responsible for resolving any failure to meet code requirements
that may be found through inspections.
• Property Damage and Liability Insurance: Homeowners acting as their own contractors should
contact their insurance agent to ensure adequate insurance coverage for accidents and omissions,
such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
redone. Liability Insurance must be sufficient to cover injuries to persons on the job site who are not
otherwise covered as employees by Workers Compensation Insurance.
• Expertise: Homeowners should make sure they have the skills to act as their own general
contractor, and the expertise required to coordinate the work of both rough-in and finish trades.
CONSTRUCTION CONTRACTORS BOARD
PO Box 14140, Salem, OR 97309-5052
Telephone: 503-378-4621 —Fax:503-373-2007
Webstte Address: www.oregon.gov/ccb
f/property_owner adopted 9-23-08 This Copy for Permit Applicant